Euthanasia (1)

The policeman's dilemma

Is it better to help someone die or leave them in unendurable suffering?

A LORRY-DRIVER is trapped in the cab of his burning vehicle after an accident. The police, fire-fighters and ambulance service are at the scene, but it is clear he will burn to death before he can be freed. He is in agony. He begs a policeman (who happens to be armed) to shoot him rather than let him burn. The officer does so. This choice—between killing someone and leaving them to die in unbearable pain—is known as the “policeman's dilemma”.

It is difficult to imagine anyone, however religious, condemning the policeman's conduct as wicked. Yet, argue the supporters of Lord Joffe's private member's bill on assisted suicide shortly to be introduced to the House of Lords, if society concedes that, then it concedes the principle of assisting death in extreme distress, where the condition is clearly terminal—as the lorry-driver's was. Only in very rare cases, reply its opponents, and the principle behind them cannot, and should not, be codified in law. Life is sacred and should not therefore be terminated by others, even on request.

And so the battle over one of the most complex, sensitive and fraught moral issues facing society rages on. This week, the House of Lords debated a select committee report on Lord Joffe's Assisted Dying for the Terminally Ill bill, an earlier version of the peer's forthcoming proposal. Under it, helping someone to end his life would become lawful, provided the patient was adult (over the age of 18), terminally ill (had only a few months left to live), mentally competent, was suffering unbearably and had made a written request for such assistance. In cases where the patient was not able on his own to administer the lethal dose, a doctor or nurse would be permitted to do so.

Since the 1961 Suicide Act, it is no longer a crime to commit suicide or attempt to do so. However, it remains unlawful, punishable by up to 14 years in prison, to “aid, abet, counsel or procure” a suicide. And deliberately taking the life of another person constitutes murder, even if the person is dying and has asked to be killed. A patient's refusal of treatment does not constitute suicide, which in law requires a “positive act”. Nor is it murder if, to relieve pain, a doctor administers a drug that as a side effect shortens the patient's life—the “double-effect principle”.

The last time Parliament picked its way through this moral mire was in 1994, when another House of Lords select committee decided not to change the law. It said you could not set limits on voluntary euthanasia (mercy-killing at the patient's request) to ensure that the law would not be abused. It foresaw a “slippery slope” in which mercy-killing slid ineluctably towards involuntary euthanasia. It was particularly worried that elderly, lonely, sick or distressed people would feel pressure, whether real or imagined, to request help with an early death, fearing they were becoming a burden on their families.

The same concerns were voiced during this week's debate in the House of Lords. But much has changed over the past decade. Legislation to permit assisted suicide and/or voluntary euthanasia has been passed in the American state of Oregon, the Netherlands and Belgium (see article). “Right-to-die” groups in Switzerland, where assisted suicide has been lawful since 1942, have begun offering help to foreigners, including Britons. Public opinion, always sympathetic, has grown even more supportive; 87% of Britons now say they want the law changed to allow people to get medical help to die. Even the medical profession, although still divided, seems to have dropped its outright opposition.

Lord Joffe, an independent crossbencher, believes he now has a real chance of success. Both a first bill, introduced in 2003, and the more restrictive second bill, on which the select committee reported, ran out of time. The third bill, in accordance with the select committee's recommendations, will drop the provision for voluntary euthanasia, under which doctors would have been permitted to intervene directly to end a terminally ill patient's life. Only assisted suicide will now be made lawful, allowing the doctor to prescribe the lethal potion, but requiring the patient to administer it himself.

But this could have the unintended effect of inducing terminally ill patients to end their lives earlier, for fear that they may later no longer be capable of doing so. Two important categories of patients are excluded from all help: those who are not terminally ill, but are nevertheless suffering “unbearably” because of a chronic illness; and those who are no longer “medically competent” or able to communicate their wishes perhaps because they are in an irreversible coma after a road accident or because of dementia.

To those who protest at the “inequity” of the bill, Lord Joffe says he is adopting a step-by-step approach. This is only a “first stage”, he says. Such comments serve to confirm the fears of those predicting a slippery slope. They draw a parallel with the 1967 Abortion Act (another private member's bill), under which the termination of a pregnancy was likewise supposed to be exceptional. Yet last year almost 200,000 abortions were carried out, nearly ten times more than in 1968. Reckonings based on experience in Oregon and the Netherlands suggest around 650 deaths a year could be expected from legalised assisted suicide, but as many as 13,000 a year from legalised voluntary euthanasia.

As with abortion, supporters of the legalisation argue that voluntary euthanasia already takes place covertly, so it would be better regulated. While surveys suggest that as many as one in seven doctors have helped patients to die at their request, the British Medical Association claims to have “no evidence whatever” of covert euthanasia. It suggests there is a confusion over the withdrawing and withholding of ineffective treatment and the provision of “double-effect” pain relief, both of which are lawful, and a deliberate act of euthanasia or assisted suicide, which is not.

Underlying the impassioned debate over Lord Joffe's bill is an age-old struggle. Which prevails: individual autonomy and freedom of choice of the most fundamental sort, or the view that human life is precious—and hence not for society to devalue as disposable and the individual to cast off? While the select committee was able to agree that in the interests of the wider community some limits should be set on patients' autonomy, it could reach no consensus on where those limits should be. The policeman's dilemma remains unresolved.